With the evolution of electronic health records (EHRs), physician practices are searching for that "tickler file" solution.
In the past, physicians would order lab work or a procedure and keep the requisition until the test results arrived either by fax or regular mail. The physician would evaluate the results and determine if it was normal or abnormal. The patient would be notified of the results and the paper copy with physician initials and date would be placed in the paper medical record. Any follow-up treatment or impressions would be noted on the lab/procedure report or in the progress notes.
This practice has not changed with the introduction of the computer. Orders are written electronically or requisitions filled out. The orders in the record are kept as a "tickler." The patient gets the lab/procedure performed. The results come back either electronically, fax, or mail. The doctor then determines the results and notifies the patient.
If results come back electronically, once reviewed by provider, the results are timed and date stamped automatically. If a hard copy is received, the physician still needs to document appropriately, including date and initials, and then scanned into the EHR system. This closes the review process and files it in the medical record.
The process of tracking lab or procedure results has not changed -- the way you do it has been modified. Always remember to document your impressions and any follow-up required.
Authored by
Allan Ridings and Joseph Wager
Senior Risk Management & Patient Safety Specialists
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.